Impact of facility-volume on achieving a textbook oncologic outcome following primary debulking surgery for advanced-stage epithelial ovarian carcinoma

Abstract

<h3>Objectives:</h3> Composite outcomes have emerged as a more accurate marker of optimal oncologic care. We evaluated the impact of facility-volume on achieving a ‘textbook oncologic outcome' (TOO) among patients diagnosed with advanced stage epithelial ovarian carcinoma (EOC) undergoing primary debulking surgery (PDS) followed by adjuvant chemotherapy. <h3>Methods:</h3> Patients diagnosed between 2004-2015 with stage IIIC-IV EOC who underwent PDS at the reporting facility followed by adjuvant chemotherapy were identified in the National Cancer Database. Annual facility PDS volume was calculated and high-volume facilities were defined those performing at least 12 PDS per year. TOO was defined as achievement of complete gross resection (CGR), no 90-day mortality, no prolonged hospitalization (>10 days), no unplanned readmission within 30-days from discharge, and initiation of adjuvant chemotherapy within 42 days from surgery and evaluated among patients with available data for all variables. Median overall survival (OS) was compared with the log-rank test and a Cox multivariate model was constructed to control for confounders. <h3>Results:</h3> A total of 19875 patients were used to calculate annual PDS facility-volume. Final analysis cohort included 6984 patients with available data for all variables of interest; 14.8% were managed at a high-volume center. A TOO was achieved for 1764 (25.3%) patients. Rate of CGR was 42.8%, while rate of prolonged hospitalization was 15.2%. Unplanned re-admission (8%) and death within 90-days (1.4%) were rare, while 28.6% of patients experienced a delay in chemotherapy administration. Patients managed at high-volume centers were more likely to achieve a TOO (28.1% vs 24.8%, p=0.022). After controlling for age, race, insurance, and comorbidities, PDS at a high-volume center was associated with a higher likelihood of achieving a TOO (OR: 1.17, 95% CI: 1.01, 1.36). Median OS of patients who did and did not achieve a TOO was 58.45 and 42.51 months respectively, p<0.001. After controlling for histology, stage, comorbidities, patient age, race, and type of insurance, TOO was associated with better survival (HR: 0.64, 95% CI: 0.59, 0.70). <h3>Conclusions:</h3> PDS at a high-volume center was associated with superior oncologic outcomes for patients with advanced-stage EOC. Centralization of care of these patients to centers of excellence should be considered.